that this manual, by bringing together successful experiences in various parts of the country, will be an inspiration to many State and local health departments to step up their effective efforts in providing better services for the aged.

Another current activity is our joint committee with the American Public Welfare Association on health problems of the aging. This joint committee, established during the current year, has brought together some outstanding figures in both the health and welfare fields for the purpose of "defining and implementing public health and public welfare responsibility for health and health related services for the aging." We hope that this can be accomplished through more effective programs within public health and public welfare agencies; and through strengthened interdepartmental cooperation.

The joint committee plans to assemble information on and publicize successful experiences in providing adequate services to the aging; to delineate areas in which public health and welfare departments can complement one another; prepare guides for State and local cooperative efforts; and encourage demonstrations and studies involving joint health and welfare department participation.

A number of other examples might be given of past and ongoing activities of the association in the field you are considering. However, I shall mention only one or two additional ones. For instance, a manual on the control of nutritional diseases in man which is now in draft form has been prepared by a subcommittee on nutrition of the standing committee on evaluation and standards. This publication will touch on the special nutritional needs of the aged and will doubtless be utilized in continuing our encouragement of nutritionist consultant services to the nursing homes and convalescent homes which are frequently deficient in this regard. And again, a special project supported by the National Institute of Mental Health is being carried out by our program area committee on mental health. This is the preparation of a program guide for public health agencies in the field of mental health. In this material the special problems of the aging will be considered and it is anticipated that additional services will result from the recommendations drafted for that publication. Possible extension of activities.-The organization of our basic membership is through 14 sections, each representing some special discipline or work area. Among those sections which have a very intimate relationship to the problems of the aging are the following: Health officers, public health nurses, dental health, engineering and sanitation, food and nutrition, medical care, mental health, and public health education. Any one of these groups either alone or with our program area committee on chronic disease and rehabilitation might well develop some special project in the field of services for the aging. Even this rather extensive list excludes some other sections that might be interested. For instance, the statistics section already has a subcommittee working on the preparation of monographs to make more rapidly available the information which will be secured through the 1960 decennial census. Much of the material which will be processed by this subcommittee will have a very definite bearing on a continuing analysis of the increasing problem of our aging population.

We have pointed out many times in the past that much of the "problem of the aging" could be prevented through public health means. More extensive use of newer public health and medical techniques on a widespread basis would certainly reduce the load of disability which must be anticipated in the growing segment of our population over 65. Training in the techniques of prevention and early diagnosis is one of the prerequisites for expanding such preventive services. The American Public Health Association has urged strongly increased Federal support for training in public health and we feel that this is one of the bottlenecks to future control of the health aspects of many of these problems.

Some specific problems of aging.-You have already received a great deal of quantitative data concerning the size of this problem and the increase which we must anticipate in the years ahead. Therefore I shall not repeat the statistics which have already been presented. You have also heard a great deal about the methods of financing additional health services to the aging and I shall not dwell extensively on that. However, before leaving the latter point, I should like to provide for the record the text of a resolution passed by the governing council of the American Public Health Association at its 86th annual meeting in St. Louis in October of 1958. It is as follows:

"Whereas health services for the aged are inadequate throughout the Nation;

and

"Whereas good health care is becoming more expensive to provide for the aged because of their high illness and disability rates, the increasing complexity and

rising costs of good care, the growing number of aged persons and their relatively small personal financial resources; and

"Whereas adequate financing is essential to support comprehensive health care of high quality for the aged; and

"Whereas the burdens of the costs of good care for the aged can be minimized for the aged, their families, contributors to voluntary insurance plans, charitable agencies, and taxpayers through arrangements, effective throughout the working lifetime, which provide paid-up insurance for the older years: Therefore be it

"Resolved, That the American Public Health Association support appropriate proposals to provide paid-up insurance for health services required by aged persons, which insurance financing should be accompanied by provisions to protect and encourage high quality care: And be it further

"Resolved, That the American Public Health Association support appropriate Federal, State, and local efforts to improve the financing and adequacy of health services for needy and medically needy aged persons through the supplementary public assistance programs and through other means, such as medical-care programs administered by health departments, and for all aged persons through public health and related programs."

Now with regard to some specific ways in which disabilities can be prevented in this segment of our population. A number of diseases which contribute very considerable numbers of disabled or bedridden patients in the later years can be reasonably well controlled if detected early. For some of these the methods of early detection are being very inadequately utilized. One example is the blindness caused by glaucoma, which, if picked up early by means of more generally available screening tests for increased ocular tension, can be much more successfully treated in those early stages. Another is diabetes, the complications of which can provide long-term disability in its later stages. Here, again, a relatively simple screening test requiring only a few drops of blood is available and has been available for a number of years, and yet is not being widely utilized. This would substantially eliminate the untreated early cases. The early detection of tuberculosis, which still contributes a very considerable portion of disability in the older age groups, has been more widely used than the two examples just mentioned. Here the focusing of case-finding efforts in those segments of the population where a high yield of tuberculosis is to be anticipated should be continued and intensified.

Another type of secondary prevention which is being inadequately utilized is the mobilizing of a series of ancillary services in the treatment of stroke resulting in hemiplegia. Many elderly people are needlessly bedridden because the services of a nurse, a physical therapist, and sometimes a homemaker are not available to the attending physician for early intensive treatment of the paralysis immediately following the cerebral accident. Some health departments have succeeded in mobilizing these community resources on an effective basis along the lines of a pattern described in the Public Health Service pamphlet called "Strike Back at Stroke" and are doing something practical about cutting down what has always been one of our major sources of disability of the aged. More should be encouraged to do likewise.

Because, as yet, at least, we can't prevent aging, there has been some tendency to assume that preventive medicine had little to offer in this segment of our population. Nothing could be further from the truth, for in all of the instances I just mentioned, plus many others, a great deal can be done right now with the services available (but inadequately coordinated) in most communities.

Another major problem is that of assuring high quality of medical and health services in any expanded program for the aging. Regarding this point, the president of the American Public Health Association, Dr. Leona Baumgartner, health commissioner of the city of New York, has recently said:

"While we in the American Public Health Association well realize that economic security and health are closely related * ** our competence is, of course, confined to health matters, and we are chiefly concerned with those provisions of the social security titles which deal with medical care for public assistance recipients and for the medically indigent.

Accumulating experience with these programs reveals some serious deficiencies and problems which are of concern to all the States. It is becoming apparent that, in the absence of any mechanism requiring the localities to establish standards of quality or to put a premium on medical excellence, the average quality of care provided over the country is not as good as it could be. Moreover, the size and scope of these programs offer many opportunities to provide better

medical care through more rational organization of services. These opportunities are being neglected. The accumulating experience which reveals these problems also provides the technology and the skill to deal with them constructively."

One of the ways in which a satisfactory level of quality has been maintained for governmentally supported medical services is represented by the program developed by the Children's Bureau for its crippled children's services. Giving considerable responsibility to States for developing their own programs but establishing certain standards (at the Federal level) for eligibility to receive Federal aid, these crippled children's programs have been highly regarded for the quality of service provided. In most instances these programs have been operated by health departments under full-time medical leadership and with very close cooperation between the official public health agency and the organized medical profession in that State. It would seem that this pattern is an extremely valuable one to keep in mind if there is to be any extension of similar services to the aging. Responsibility of official and voluntary groups at various levels.—In a questionnaire which went out from the American Public Health Association at the end of 1958 to all State health officers and to a selected group of city and county health officers, we inquired about the relative importance of various newly emerging health problems and of long standing health problems. In both categories our respondents listed the problems of aging and of chronic diseases very high in their sequence of priorities. They also indicated that if additional personnel and finances were available to them the problems of chronic disease and of services to the aging would receive special consideration. These are indications of a growing awareness on the part of public health officials at both State and local levels of the need for additional attention in this area.

Although the American Public Health Association has not taken a specific stand on the respective roles to be played by national, State, and local agencies, or by voluntary and official agencies in this field, I should like to offer some suggestions based on my own personal experience. When we are dealing with a health program requiring personal services to the individual, whether they be medical, dental, nursing, physical therapy, nutrition or homemaker, the immediate provision of such services or arrangement for their provision can be done better at the local than at either State or Federal levels. We have a great potential in this country of personnel already trained in health matters, and employed by local health departments whose time has been taken up in the past with the control of communicable diseases or those transmitted by water, milk, and food. A great deal more can be done by the public health nurses and the visiting nurse associations of this country to provide adequate home care for the aged. And more can be done by trained medical health officers acting as consultants to the medicalcare programs operated by welfare departments.

But there are many interagency relationships that have not been established which would have to be arranged before these personnel can be used to maximum advantage. Primarily these are relationships between local health departments and local welfare departments. As indicated earlier, studies of these interrelationships of associations are going on now between the American Public Health Association and the American Public Welfare Association.

For example, in some areas the licensing and control of nursing homes is a responsibility of the welfare department. Even while this remains so, it should be possible through interagency arrangements to utilize nutritionists from the health department to advise nursing home operators of the best utilization of their daily diets; to utilize the sanitation personnel of the health department for assurance of proper safety and sanitary standards; and to utilize public health nurse consultation as the basis for improving the continuity of good nursing care. Subjects, such as the periodicity of medical review of cases, should be considered; as should the manner in which drugs and other medications are procured and stored; and also the utilization of all available rehabilitation resources of the community so that bedridden patients might not always expect to be doomed to that state. There has been a grave fragmentation of community services to the aged. In some instances this can certainly be corrected by the reshuffling of responsibilities to provide most of them in a single department. But this is not the only solution and in some instances is not the best solution. Joint planning by health and welfare agencies is doubtless the proper place to start; a clear-cut division of responsibilities with the health department delegated those justified by its competencies would be a second step; and where multiagency authority and administrative responsibility appear to be desirable there can still be a close working relationship on the basis of interagency consultation.

In any event, it would seem that we should not continue indefinitely to talk about and think about only the "problems of the aging." It would be much more constructive if we occasionally dwelt on the tremendous unrealized potential afforded us by these experienced and skilled older persons, many of whom are the wisest among us, and to think, rather, of all of the ways in which we can be assured of their continued productivity and contributions to the community in which they live. These are people we are talking about, not statistics. The conservation of their future contributions to society will not be made by money alone, nor by correction or prevention of their physical defects. They must be assured of a respected place in their community where they will be enabled to continue to be a partner, not a problem.

Senator MCNAMARA. We will be glad to have you proceed in whatever manner you choose.

Dr. MATTISON. Mr. Chairman, I would like to start by thanking you and the committee for an opportunity to express some of the thoughts of the American Public Health Association on this matter and problems of the aging.

It is a problem in which I have been personally interested for a number of years and, as a member of the Advisory Committee to the White House Conference on Aging, I am particularly happy to be here and to hear the other testimony which has been given this morning.

I would like to mention very briefly some of the ways in which the American Public Health Association has a role in solving these problems.

First of all, we have affiliates in 42 of the 50 States, and about 25,000 total members in these affiliates as well as in the American Public Health Association itself, which makes us one of the largest public health professional organizations in the world.

Our role in this, as in other health problems, is primarily made up of the scientific part of our work, stimulation of the professional workers throughout our scientific sessions and through our journal and other publications, through the establishment of standards in various fields of public health practice, qualifications of public health personnel, through the development of manuals of public health practice. For instance, right now we are putting together and have in a draft form a manual on chronic disease programs, which will affect the prac tice of many health departments in the country.

Our role is also in the development of interagency relationships and interagency projects in the field of health and welfare, together with training which we realize is one of the major needs in the field of public health on which we have testified before another committee this year in an attempt to get additional support for training in public health.

Now, with regard to the problems as we see them and as we think we can help:

First of all, I am not going to give you any statistics, and there is none in my testimony, for you have previously received many data on this problem. However, the American Public Health Association is aware of the statistics, recognizes the problem, and believes that the present health services are definitely inadequate for the aging population.

In this listing of the general problem areas there is, of course, the medical care problem. We feel that there is going to be no easy solution to this, that there will have to be an increase in quantity and a series of methods of providing medical care. There has been insuf

ficient use of the progressive care concept providing the very best care for the acutely ill, for the less acutely ill, those who are capable of self-help and those who should be cared for in the home. Part of the economic problem of providing medical care can be solved through the application of the progressive care concept.

I would like to quote briefly from my statement with regard to a resolution passed by the American Public Health Association on this matter of health services.

On page 5, simply the two paragraphs that have to do with the items under which we specifically resolved.

Resolved, That the American Public Health Association support appropriate proposals to provide paid-up insurance for health services required by aged persons, which insurance financing should be accompanied by provisions to protect and encourage high quality care; and be it further

Resolved, That the American Public Health Association support appropriate Federal, State, and local efforts to improve the financing and adequacy of health services for needy and medically needy aged persons through the supplementary public assistance programs and through other means such as medical care programs administered by health departments, and for all aged persons through public health and related programs.

The second problem area-and this, of course, is one we are particularly interested in-as we see it, is that of the prevention of disability. The application of public health techniques in the past has had a very real effect on the present level of disability among the aged. For instance, tuberculosis programs have relieved a great number of elderly people of their disabling conditions. The same thing is true of venereal disease programs. There used to be literally tens of thousands of elderly people suffering from cardiac disability and central nervous system lesions of syphilis because of the absence of prevention, as we think of it now.

There are a couple of other programs which have not been sufficiently utilized in the preventive field. One is early case finding of diabetics. There is a perfectly good screen test for diabetes which has been used in some communities rather extensively but has not been used widely enough, which would help us pick up diabetics and get them under treatment before many of the complications which have previously plagued the elderly people developed. The same can be said of the problem of early case finding of glaucoma.

Then there are a series of things which some health departments have done in the prevention of secondary effects, for instance, in stroke, hemiplegia some departments have mobilized whole series of services and public health nurses and visiting nurses, physical therapy, nutritionists, sometimes psychologists working with the private physician, or early intensive home therapy of these hemiplegics. This is preventive service. In those areas where it has been applied it has prevented a great deal of disability.

The more extensive use of nutrition services in nursing homes would also be a very sound preventive. The inadequacies of nutrition in some of the homes for the elderly are recognized and correction would prevent some of the disabilities that we see.

More home nursing through the transfer of public health nurses away from the communicable diseases and problems of childhood to the problems of the chronically ill would also prevent some of the disability which occurs in long-term bedridden cases that do not really have to be bedridden.